Bag-Valve-Mask Ventilation and Survival From Out-of-Hospital Cardiac Arrest: A Multicenter Study.

BACKGROUND: Few studies have measured ventilation during early cardiopulmonary resuscitation (CPR) before advanced airway placement. Resuscitation guidelines recommend pauses after every 30 chest compressions to deliver ventilations. The effectiveness of bag-valve-mask ventilation delivered during the pause in chest compressions is unknown. We sought to determine: (1) the incidence of lung inflation with bag-valve-mask ventilation during 30:2 CPR; and (2) the association of ventilation with outcomes after out-of-hospital cardiac arrest. METHODS: We studied patients with out-of-hospital cardiac arrest from 6 sites of the Resuscitation Outcomes Consortium CCC study (Trial of Continuous Compressions versus Standard CPR in Patients with Out-of-Hospital Cardiac Arrest). We analyzed patients assigned to the 30:2 CPR arm with ≥2 minutes of thoracic bioimpedance signal recorded with a cardiac defibrillator/monitor. Detectable ventilation waveforms were defined as having a bioimpedance amplitude ≥0.5 Ω (corresponding to ≥250 mL VT) and a duration ≥1 s. We defined a chest compression pause as a 3- to 15-s break in chest compressions. We compared the incidence of ventilation and outcomes in 2 groups: patients with ventilation waveforms in <50% of pauses (group 1) versus those with waveforms in ≥50% of pauses (group 2). RESULTS: Among 1976 patients, the mean age was 65 years; 66% were male. From the start of chest compressions until advanced airway placement, mean±SD duration of 30:2 CPR was 9.8±4.9 minutes. During this period, we identified 26 861 pauses in chest compressions; 60% of patients had ventilation waveforms in <50% of pauses (group 1, n=1177), and 40% had waveforms in ≥50% of pauses (group 2, n=799). Group 1 had a median of 12 pauses and 2 ventilations per patient versus group 2, which had 12 pauses and 12 ventilations per patient. Group 2 had higher rates of prehospital return of spontaneous circulation (40.7% versus 25.2%; P<0.0001), survival to hospital discharge (13.5% versus 4.1%; P<0.0001), and survival with favorable neurological outcome (10.6% versus 2.4%; P<0.0001). These associations persisted after adjustment for confounders. CONCLUSIONS: In this study, lung inflation occurred infrequently with bag-valve-mask ventilation during 30:2 CPR. Lung inflation in ≥50% of pauses was associated with improved return of spontaneous circulation, survival, and survival with favorable neurological outcome.

Telecommunicator Cardiopulmonary Resuscitation: A Policy Statement From the American Heart Association.

Every year in the United States, >350 000 people have sudden cardiac arrest outside of a hospital environment. Sudden cardiac arrest is the unexpected loss of heart function, breathing, and consciousness and is commonly the result of an electric disturbance in the heart. Unfortunately, only ≈1 in 10 victims survives this dramatic event. Early access to 9-1-1 and early cardiopulmonary resuscitation (CPR) are the first 2 links in the chain of survival for out-of-hospital cardiac arrest. Although 9-1-1 is frequently accessed, in the majority of cases, individuals with out-of-hospital cardiac arrest do not receive lay rescuer CPR and wait for the arrival of professional emergency rescuers. Telecommunicators are the true first responders and a critical link in the cardiac arrest chain of survival. In partnership with the 9-1-1 caller, telecommunicators have the first opportunity to identify a patient in cardiac arrest and provide initial care by delivering CPR instructions while quickly dispatching emergency medical services. The telecommunicator and the caller form a unique team in which the expertise of the telecommunicator is provided just in time to a willing caller, transforming the caller into a lay rescuer delivering CPR. The telecommunicator CPR (T-CPR) process, also previously described as dispatch CPR, dispatch-assisted CPR, or telephone CPR, represents an important opportunity to improve survival from sudden cardiac arrest. Conversely, failure to provide T-CPR in this manner results in preventable harm. This statement describes the public health impact of out-of-hospital cardiac arrest, provides guidance and resources to construct and maintain a T-CPR program, outlines the minimal acceptable standards for timely and high-quality delivery of T-CPR instructions, and identifies strategies to overcome common implementation barriers to T-CPR.

Out-of-Hospital Research in the Era of Electronic Health Records.

Conducting out-of-hospital research is unique and challenging and requires tracking patients across multiple phases of care, using multiple sources of patient records and multiple hospitals. The logistics and strategies used for out-of-hospital research are distinct from other forms of clinical research. The increasing use of electronic health records (EHRs) by hospitals and emergency medical services (EMS) agencies presents a large opportunity for accelerating out-of-hospital research, as well as particular challenges. In this study, we describe seven key aspects of designing and implementing out-of-hospital research in the era of EHRs: (1) selection of research sites, (2) defining the patient population, (3) patient sampling and sample size calculations, (4) EMS data, (5) hospital selection, (6) handling missing data, and (7) statistical analysis. We use examples from a recent prospective out-of-hospital cohort study to illustrate these topics, including lessons learned.

Resuscitation Outcomes Consortium-Amiodarone, Lidocaine or Placebo Study (ROC-ALPS): Rationale and methodology behind an out-of-hospital cardiac arrest antiarrhythmic drug trial.

BACKGROUND: Despite their wide use, whether antiarrhythmic drugs improve survival after out-of-hospital cardiac arrest (OHCA) is not known. The ROC-ALPS is evaluating the effectiveness of these drugs for OHCA due to shock-refractory ventricular fibrillation or pulseless ventricular tachycardia (VF/VT). METHODS: ALPS will randomize 3,000 adults across North America with nontraumatic OHCA, persistent or recurring VF/VT after ≥1 shock, and established vascular access to receive up to 450 mg amiodarone, 180 mg lidocaine, or placebo in the field using a double-blind protocol, along with standard resuscitation measures. The designated target population is all eligible randomized recipients of any dose of ALPS drug whose initial OHCA rhythm was VF/VT. A safety analysis includes all randomized patients regardless of their eligibility, initial arrhythmia, or actual receipt of ALPS drug. The primary outcome of ALPS is survival to hospital discharge; a secondary outcome is functional survival at discharge assessed as a modified Rankin Scale score ≤3. RESULTS: The principal aim of ALPS is to determine if survival is improved by amiodarone compared with placebo; secondary aim is to determine if survival is improved by lidocaine vs placebo and/or by amiodarone vs lidocaine. Prioritizing comparisons in this manner acknowledges where differences in outcome are most expected based on existing knowledge. Each aim also represents a clinically relevant comparison between treatments that is worth investigating. CONCLUSIONS: Results from ALPS will provide important information about the choice and value of antiarrhythmic therapies for VF/VT arrest with direct implications for resuscitation guidelines and clinical practice.

Treatment of cardiac arrest with rapid defibrillation by police in King County, Washington.

BACKGROUND: Improving survival from out-of-hospital cardiac arrest is an ongoing challenge for emergency medical services (EMS). Various strategies for shortening the time from collapse to defibrillation have been used, and one is to equip police officers with defibrillators. Objective. We evaluated the programmatic implementation of police defibrillation to determine if such a program could improve the process of care in a high-functioning and mature EMS system. METHODS: We conducted a prospective observational study of implementation of a police defibrillation in two police departments in King County, Washington, from March 1, 2010 to March 31, 2012. The program was designed to dispatch police specifically to cases with a high suspicion of cardiac arrest, defined as a patient who was unconscious and not breathing normally. We included all nontraumatic out-of-hospital cardiac arrest events that occurred prior to EMS arrival and within the city limits of the two cities. We collected both EMS and police dispatch reports to document times of call receipt, dispatch, and arrival of both agencies. We obtained rhythm recordings when the automated external defibrillators (AEDs) were used by the police. Descriptive statistics were used to measure frequency of police dispatch and to compare times to treatment between patients with a police response and those without. RESULTS: During the study period there were 231 cases of cardiac arrest that occurred prior to EMS arrival eligible for police response in the study communities. Police were dispatched to 124 (54%) of these cases. Of the 124, the police arrived before EMS 37 times, or 16% of the 231 cases. Police performed CPR in 29 of these cases and applied the AED in 21 of them. Of the 21 cases in which the AED was applied for cardiac arrest, a shock was delivered on first analysis for 6 patients. Although the response interval between dispatch to scene arrival was similar for EMS and police (4.5 minutes versus 4.6 minutes respectively, p = 0.08), police were dispatched considerably slower than EMS (1.8 minutes versus 0.6 minutes, p < 0.001). CONCLUSIONS: In the current programmatic implementation, police had a measurable but limited involvement in resuscitation. Efforts to address dispatch challenges may improve police involvement.

Wolf Creek XVII Part 6: Physiology-Guided CPR.

Introduction: Physiology-guided cardiopulmonary resuscitation (CPR) offers the potential to optimize resuscitation and enable early prognosis. Methods: Physiology-Guided CPR was one of six focus topic for the Wolf Creek XVII Conference held on June 14-17, 2023 in Ann Arbor, Michigan, USA. International thought leaders and scientists in the field of cardiac arrest resuscitation from academia and industry were invited. Participants submitted via online survey knowledge gaps, barriers to translation and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category, which was then debated, revised and ranked by all attendees to identify the top 5 for each category. Results: Top knowledge gaps include identifying optimal strategies for the evaluation of physiology-guided CPR and the optimal values for existing patients using patient outcomes. The main barriers to translation are the limited usability outside of critical care environments and the training and equipment required for monitoring. The top research priorities are the development of clinically feasible and reliable methods to continuously and non-invasively monitor physiology during CPR and prospective human studies proving targeting parameters during CPR improves outcomes. Conclusion: Physiology-guided CPR has the potential to provide individualized resuscitation and move away from a one-size-fits-all approach. Current understanding is limited, and clinical trials are lacking. Future developments need to consider the clinical application and applicability of measurement to all healthcare settings. Therefore, clinical trials using physiology-guided CPR for individualisation of resuscitation efforts are needed.

Perishock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest.

BACKGROUND: Perishock pauses are pauses in chest compressions before and after defibrillatory shock. We examined the relationship between perishock pauses and survival to hospital discharge. METHODS AND RESULTS: We included out-of-hospital cardiac arrest patients in the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest who suffered arrest between December 2005 and June 2007, presented with a shockable rhythm (ventricular fibrillation or pulseless ventricular tachycardia), and had cardiopulmonary resuscitation process data for at least 1 shock (n=815). We used multivariable logistic regression to determine the association between survival and perishock pauses. In an analysis adjusted for Utstein predictors of survival, the odds of survival were significantly lower for patients with preshock pause ≥20 seconds (odds ratio, 0.47; 95% confidence interval, 0.27 to 0.82) and perishock pause ≥40 seconds (odds ratio, 0.54; 95% confidence interval, 0.31 to 0.97) compared with patients with preshock pause <10 seconds and perishock pause <20 seconds. Postshock pause was not independently associated with a significant change in the odds of survival. Log-linear modeling depicted a decrease in survival to hospital discharge of 18% and 14% for every 5-second increase in both preshock and perishock pause interval (up to 40 and 50 seconds, respectively), with no significant association noted with changes in the postshock pause interval. CONCLUSIONS: In patients with cardiac arrest presenting in a shockable rhythm, longer perishock and preshock pauses were independently associated with a decrease in survival to hospital discharge. The impact of preshock pause on survival suggests that refinement of automatic defibrillator software and paramedic education to minimize preshock pause delays may have a significant impact on survival.

Emergency communications with limited-English-proficiency populations.

OBJECTIVE: We investigated 9-1-1 telecommunicators' perceptions of communication difficulties with callers who have limited English proficiency (LEP) and the frequency and outcomes of specific communication behaviors. METHODS: A survey was administered to 150 telecommunicators from four 9-1-1 call centers of a metropolitan area in the Pacific Northwest to assess their experience working with LEP callers. In addition, 172 9-1-1 recordings (86 of which were labeled by telecommunicators as having a "language barrier") were abstracted for telecommunicators' communication behaviors and care delivery outcomes. All recordings were for patients who were in presumed cardiac arrest (patient unconscious and not breathing). Additionally, computer-assisted dispatch (CAD) reports were abstracted to assess dispatch practices with regard to timing of basic life support (BLS) and advanced life support (ALS) dispatch. RESULTS: One hundred twenty-three of the telecommunicators (82%) filled out the survey. The majority (70%) reported that they encounter LEP callers almost daily and most (78%) of them reported that communication difficulties affect the medical care these callers receive. Additionally, the telecommunicators reported that calls with LEP callers are often (36%) stressful. The number one strategy for communication with LEP callers reported by telecommunicators was the use of a telephone interpreter line known as the Language Line. However, the Language Line was utilized in only 13% of LEP calls abstracted for this study. The analysis of 9-1-1 recordings suggests that the LEP callers received more repetition, rephrasing, and slowing of speech than the non-LEP callers. Although there was no difference in time from onset of call to dispatching BLS, there was a significant difference in simultaneous dispatching of BLS and ALS between the LEP calls (20%) and non-LEP calls (38%, p < 0.05). CONCLUSION: Our study shows that 9-1-1 telecommunicators believe language barriers with LEP callers negatively impact communication and care outcomes. More research needs to be conducted on "best practices" for phone-based emergency communication with LEP callers. Additionally, LEP communities need to better understand the 9-1-1 system and how to effectively communicate during emergencies.

Out-of-hospital fluid in severe sepsis: effect on early resuscitation in the emergency department.

BACKGROUND: Early identification and treatment of patients with severe sepsis improves outcome, yet the role of out-of-hospital intravenous (IV) fluid is unknown. OBJECTIVE: To determine if the delivery of out-of-hospital fluid in patients with severe sepsis is associated with reduced time to achievement of goal-oriented resuscitation in the emergency department (ED). METHODS: We performed a secondary data analysis of a retrospective cohort study in a metropolitan, tertiary care, university-based medical center supported by a two-tiered system of out-of-hospital emergency medical services (EMS) providers. We studied the association between delivery of out-of-hospital fluid by advanced life support (ALS) providers and the achievement of resuscitation endpoints (central venous pressure [CVP] > or =8 mmHg, mean arterial pressure [MAP] > or =65 mmHg, and central venous oxygen saturation [ScvO(2)] > or =70%) within six hours after triage during early goal-directed therapy (EGDT) in the ED. RESULTS: Twenty five (48%) of 52 patients transported by ALS with severe sepsis received out-of-hospital fluid. Data for age, gender, source of sepsis, and presence of comorbidities were similar between patients who did and did not receive out-of-hospital fluid. Patients receiving out-of-hospital fluid had lower out-of-hospital mean (+/- standard deviation) systolic blood pressure (95 +/- 40 mmHg vs. 117 +/- 29 mmHg; p = 0.03) and higher median (interquartile range) Sequential Organ Failure Assessment (SOFA) scores in the ED (7 [5-8] vs. 4 [4-6]; p = 0.01) than patients not receiving out-of-hospital fluid. Despite greater severity of illness, patients receiving out-of-hospital fluid approached but did not attain a statistically significant increase in the likelihood of achieving MAP > or =65 mmHg within six hours after ED triage (70% vs. 44%, p = 0.09). On average, patients receiving out-of-hospital fluid received twice the fluid volume within one hour after ED triage (1.1 L [1.0-2.0 L] vs. 0.6 L [0.3-1.0 L]; p = 0.01). No difference in achievement of goal CVP (72% vs. 60%; p = 0.6) or goal ScvO(2) (54% vs. 36%; p = 0.25) was observed between groups. CONCLUSIONS: Less than half of patients with severe sepsis transported by ALS received out-of-hospital fluid. Patients receiving out-of-hospital IV access and fluids approached but did not attain a statistically significant increase in the likelihood of achieving goal MAP during EGDT. These preliminary findings require additional investigation to evaluate the optimal role of out-of-hospital resuscitation in treating patients with severe sepsis.

Reasons 9-1-1 is called for cardiac arrest cases in which no resuscitation is attempted.

OBJECTIVE: The goal of this investigation was to describe the reasons emergency medical services (EMS) is activated when resuscitation is not desired or when patients show signs of irreversible death. METHODS: All medical incident report forms (MIRFs) indicating a cardiac arrest for which resuscitation was withheld were obtained from five participating fire departments. For each eligible case (N = 196), one of the emergency medical technicians (EMTs) present at the scene was interviewed and the dispatch tape of the 9-1-1 call was reviewed. Patient and caller characteristics were abstracted from the MIRFs and dispatch tapes. The EMTs were asked about the reasons for the call, whether the family expected this death, and the caller's emotional state when EMS arrived at the scene. In addition, EMS providers were asked open-ended questions about the services they provided for the patient and patient's family. Using chi-square statistics and t-tests, we compared two groups: 1) patients for whom resuscitation was not desired as indicated by a do-not-resuscitate (DNR) order, terminal illness, or hospice (n = 66) and 2) patients for whom resuscitation was not started because of signs of irreversible death (n = 130). RESULTS: Compared with callers for patients with signs of irreversible death, callers for patients for whom resuscitation was not desired were less likely to access EMS because they needed medical assistance (11% versus 30%) and more likely to call 9-1-1 because they thought it was "required by law" (30% versus 8%). Other common reasons in both groups for activating 9-1-1 were confusion regarding what to do and a request to confirm death. The most frequently reported service provided by EMTs for both groups was to "offer to contact a chaplain." CONCLUSION: In a third of patients for whom EMS did not initiate resuscitation, resuscitation was withheld primarily because it was not desired rather than because there was evidence of irreversible death. Efforts to improve education may prevent EMS activation in these cases. An alternative EMS response could also help ensure patient autonomy and decrease costs to the EMS system.

Medic One Pediatric (MOPed) cards: standardising paramedic paediatric resuscitation.

OBJECTIVE: Paediatric resuscitation is highly stressful, technically challenging and infrequently performed by paramedics. Length-based equipment selection, weight-based medication dosing and less familiar paediatric clinical scenarios create high cognitive load. Our project aimed to decrease cognitive load and increase paramedic comfort by providing standardised paediatric resuscitation cards across an entire Emergency Medical Services (EMS) system. METHODS: After 2 years of collaboration between EMS and regional paediatric subspecialists, we created and implemented a novel set of length-based, colour-coded cards: Medic One Pediatric (MOPed) cards. MOPed cards standardise the approach to paediatric scenarios, such as rapid sequence intubation (RSI), seizure management and cardiac arrest. We standardised drug concentrations across all five EMS agencies to allow for volume-based dosing, removing medication calculations, simplifying the process of medication administration and potentially decreasing both calculation error and time to intervention. We consolidated medications on MOPed cards to the 12 most commonly used in Paediatric Advanced Life Support scenarios. We surveyed 240 EMS personnel before and after implementation to determine use and effect on paramedic comfort. RESULTS: After 12 months of implementation, 97% of respondents reported using the new cards as their primary reference, and 94% reported improved speed and accuracy of medication administration. Specifically, RSI medication administration received the greatest improvement in comfort (p=0.001). Additionally, paramedics increased the use of MOPed cards when selecting endotracheal tubes: 45% of the respondents had done so by 6 months, and 60% had done so after 12 months of implementation (p=0.01). CONCLUSIONS: MOPed cards were well adopted across a large EMS system, with improvement in paramedic comfort in managing some paediatric resuscitation scenarios.

Bystander automated external defibrillator application in non-shockable out-of-hospital cardiac arrest.

BACKGROUND: An increasing proportion of patients with OHCA present with non-shockable rhythms, among whom the benefit from AED application is not known. METHODS: We performed a retrospective analysis of adults with non-traumatic, public, bystander-witnessed, non-shockable OHCA occurring between 2005-2015 at 9 locations participating in the Resuscitation Outcomes Consortium. Non-shockable arrest was defined as when no shock was administered by a bystander applied AED and confirmed by the initial rhythm on EMS arrival. Outcomes were compared between patients with non-shockable OHCA in whom a bystander AED was or was not applied. RESULTS: Among 2809 patients with non-shockable public, witnessed OHCA, 8.4% had an AED applied. CPR was more often performed in the AED-applied group (99% vs. 51% of patients, p < 0.001). Among patients in whom an AED was not applied, 39.8% had any pre-hospital ROSC, 29.6% had a pulse at ED arrival and 11.1% survived to hospital discharge compared to 44.1%, 29.6% and 9.7%, respectively with AED application. After adjustment for the Utstein variables excluding bystander CPR, the OR for survival to hospital discharge for AED application was 0.90 (95% CI:0.57-1.42); when adjusted for the higher frequency of CPR in the AED group the OR was 0.92 (95% CI:0.57-1.47). CONCLUSIONS: The application of an AED in non-shockable public witnessed OHCA was associated with a higher frequency of bystander CPR. The probabilities of pre-hospital ROSC, pulse at ED arrival, and survival to hospital discharge were not altered by the application of an AED.

Cardiac arrest in schools.

BACKGROUND: The purpose of the present study is to improve understanding of the epidemiology of cardiac arrest in the school setting, with a special focus on the role of school-based automated external defibrillators. METHODS AND RESULTS: The investigation was a retrospective study of emergency medical service-treated, nontraumatic, out-of-hospital cardiac arrests in Seattle and King County, Washington, that occurred in schools between 1990 and 2005. Cases were identified with cardiac arrest location data from emergency medical service cardiac arrest registries. Patient characteristics, cardiac arrest characteristics, and outcome information were abstracted from the registries and incident report forms. During the study period, 97 cardiac arrests occurred in schools, accounting for 0.4% of all treated cardiac arrests and 2.6% of public location cardiac arrests. Of the 97 cases, 12 cardiac arrests were among students, 33 among faculty and staff, and 45 among adults not employed by the school (7 adults with indeterminate school association). School-based cardiac arrest occurred on average in 1 of 111 schools annually, with a greater annual incidence among colleges (1 cardiac arrest per 8 colleges) than high schools (1 per 125 high schools) or lower-level schools (1 cardiac arrest per 200 preschools through middle schools). The estimated annual incidence of cardiac arrest was 0.18 per 100,000 person-years among students and 4.51 per 100,000 person-years for school faculty and staff. CONCLUSIONS: The present study characterizes school-setting cardiac arrest and provides a framework within which to consider preparation efforts and outcome expectations.

Ventricular fibrillation in King County, Washington: a 30-year perspective.

AIM: We determined the effect of four major program changes over a 30-year period on survival from witnessed cardiac arrest (CA) with ventricular fibrillation (VF) as the rhythm causing collapse. METHODS: We conducted an investigation of emergency medical services (EMS)-treated CA occurring between 1978 and 2007. Data were obtained from a registry maintained by the King County Emergency Medical Services Division. Using Utstein style definitions, we measured changes in patient survival in light of four programs that were implemented during the span of the study: defibrillation by emergency medical technicians (EMTs), dispatcher-assisted cardiopulmonary resuscitation (CPR), public access defibrillation, and a CPR-defibrillation protocol that replaced delivery of three sequential shocks with administration of one shock followed by 2 min of CPR. RESULTS: Overall survival from witnessed VF during the study period was 34%. While demographic characteristics of patients in CA remained constant, we observed greater rates of survival in the years following the program changes, 1983-2006, compared to survival in the period before the changes, 1977-1982. The greatest increase in survival occurred following the CPR-defibrillation protocol change in 2005. CONCLUSION: Despite adverse temporal trends, the four program changes appear to have contributed to increasing survival rates from out-of-hospital cardiac arrests in King County.

Regional variation in out-of-hospital cardiac arrest incidence and outcome.

CONTEXT: The health and policy implications of regional variation in incidence and outcome of out-of-hospital cardiac arrest remain to be determined. OBJECTIVE: To evaluate whether cardiac arrest incidence and outcome differ across geographic regions. DESIGN, SETTING, AND PATIENTS: Prospective observational study (the Resuscitation Outcomes Consortium) of all out-of-hospital cardiac arrests in 10 North American sites (8 US and 2 Canadian) from May 1, 2006, to April 30, 2007, followed up to hospital discharge, and including data available as of June 28, 2008. Cases (aged 0-108 years) were assessed by organized emergency medical services (EMS) personnel, did not have traumatic injury, and received attempts at external defibrillation or chest compressions or resuscitation was not attempted. Census data were used to determine rates adjusted for age and sex. MAIN OUTCOME MEASURES: Incidence rate, mortality rate, case-fatality rate, and survival to discharge for patients assessed or treated by EMS personnel or with an initial rhythm of ventricular fibrillation. RESULTS: Among the 10 sites, the total catchment population was 21.4 million, and there were 20,520 cardiac arrests. A total of 11,898 (58.0%) had resuscitation attempted; 2729 (22.9% of treated) had initial rhythm of ventricular fibrillation or ventricular tachycardia or rhythms that were shockable by an automated external defibrillator; and 954 (4.6% of total) were discharged alive. The median incidence of EMS-treated cardiac arrest across sites was 52.1 (interquartile range [IQR], 48.0-70.1) per 100,000 population; survival ranged from 3.0% to 16.3%, with a median of 8.4% (IQR, 5.4%-10.4%). Median ventricular fibrillation incidence was 12.6 (IQR, 10.6-5.2) per 100,000 population; survival ranged from 7.7% to 39.9%, with a median of 22.0% (IQR, 15.0%-24.4%), with significant differences across sites for incidence and survival (P<.001). CONCLUSION: In this study involving 10 geographic regions in North America, there were significant and important regional differences in out-of-hospital cardiac arrest incidence and outcome.

Psychological and social impacts of automated external defibrillators (AEDs) in the home.

BACKGROUND: The majority of cardiac arrests occur in the home. The placement of AEDs in the homes of at-risk patients may save lives through early defibrillation. However, the impact of having an AED in the home on psychological outcomes and quality-of-life is unknown. OBJECTIVE: The purpose of this research was to determine whether training in the use of and possessing an automated external defibrillator (AED) has an effect on a patient at risk's quality of life. METHODS: We investigated the psychological consequences of AED training and possession of such a device for patients who recently experienced an acute ischemic event. One hundred fifty eight patients and their family members were assigned at random to receive cardiopulmonary resuscitation (CPR) training (N=66) or AED/CPR training and possession of the device after training (N=92). We measured quality of life using the Short-Form (SF-36) survey and a 9-item survey we developed specifically for this study to measure differences in social activities and worries about being left alone. Participants answered these questions at enrollment, 2 weeks, 3 months, and 3 months after enrollment. RESULTS: Patients in the AED group reported lower (worse) scores on most SF-36 subscales at all periods, particularly in those subscales relating to social functioning. The differences were most often small and probably not clinically meaningful. The social activities/worry scales also favored the CPR group at all periods, but with no significant differences. CONCLUSIONS: Physicians counselling patients about AEDs should be aware of the potential effects the device may have on a patient's social functioning.

Intraosseous compared to intravenous drug resuscitation in out-of-hospital cardiac arrest.

AIMS: Although the intraosseous (IO) route is increasingly used for vascular access in out-of-hospital cardiac arrest (OHCA), little is known about its comparative effectiveness relative to intravenous (IV) access. We evaluated clinical outcomes following OHCA comparing drug administration via IO versus IV routes. METHODS: This retrospective cohort study evaluated Emergency Medical Services (EMS)-treated adults with atraumatic OHCA in a large metropolitan EMS system between 9/1/2012-12/31/2014. Access was classified as IO or IV based on the route of first EMS drug administration. Study endpoints were survival to hospital discharge, return of spontaneous circulation (ROSC) and survival to hospital admission. RESULTS: Among 2164 adults with OHCA, 1800 met eligibility criteria, 1525 of whom were treated via IV and 275 principally via tibial-IO routes. Compared to IV, IO-treated patients were younger, more often women, had unwitnessed OHCA, a non-cardiac aetiology, and presented with non-shockable rhythms. IO versus IV-treated patients were less likely to survive to hospital discharge (14.9% vs 22.8%, p=0.003), achieve ROSC (43.6% vs 55.5%, p<0.001) or be hospitalized (38.5% vs 50.0% p<0.001). In multivariable adjusted analyses, IO treatment was not associated with survival to discharge (odds ratio (OR) (95% confidence interval) 0.81 (0.55, 1.21), p=0.31), but was associated with a lower likelihood of ROSC (OR=0.67 (0.50, 0.88), p=0.004) and survival to hospitalization (OR=0.68 (0.51, 0.91), p=0.009). CONCLUSION: Though not independently associated with survival to discharge, principally tibial IO versus IV treatment was associated with a lower likelihood of ROSC and hospitalization. How routes of vascular access influence clinical outcomes after OHCA merits additional study.